Interpretive Summary: The evidence of increasing phosphorus intake is clear, with more compounds being added to the food supply and more foods consumed as process or pre-prepared, the risk of intake of high levels of phosphorus that may have negative health effects is feasible for large segments of the population. Beyond that, there is accumulating evidence that both the high intakes and the poor balance of intake with other nutrients may place individuals at risk of kidney disease, bone loss, cardiovascular disease, and other chronic health conditions. This paper summarizes research findings on the level of phosphorus in the diet of the population, food and beverages source of phosphorus in the diet as well as the increase of phosphate additives in the U.S. food supply and discusses considerations for improving nutrition surveillance and research designs to identify potential risks on chronic disease outcomes impacted by phosphorus exposure and bioavailability.

Technical Abstract:
The Western dietary pattern of intake common to many Americans is high in fat, refined carbohydrates, sodium, and phosphorus, all of which are associated with processed food consumption and higher risk of life-threatening chronic diseases. In this review, we focus on the available information on current phosphorus intake with this Western dietary pattern and new knowledge of how the disruption of phosphorus homeostasis can occur when intake of phosphorus far exceeds nutrient needs and calcium intake is limited. Elevation of extracellular phosphorus, even when phosphorus intake is seemingly modest but excessive relative to need and calcium intake, may disrupt the endocrine regulation of phosphorus balance in healthy individuals, as it is known to do in renal disease. This elevation in serum phosphate, whether episodic or chronically sustained, may trigger the secretion of regulatory hormones, whose actions can damage tissue leading to the development of cardiovascular disease, renal impairment, and bone loss. Therefore, we assessed the health impact of excess phosphorus intake in the context of specific issues that reflect changes over time in the U.S. food supply and patterns of intake. Important issues include food processing and food preferences, the need to evaluate phosphorus intake in relation to calcium intake and phosphorus bioavailability, the accuracy of various approaches used to assess phosphorus intake, and the difficulties encountered in evaluating the relationship of phosphorus intake to chronic disease markers or incident disease.